Rates of women who are opting for preventive mastectomies, such as Angeline Jolie, have increased by an estimated 50 percent in recent years, experts say. But many doctors are puzzled because the operation doesn't carry a 100 percent guarantee, it's major surgery -- and women have other options, from a once-a-day pill to careful monitoring.

But Spady, a 54-year-old emergency physician in rural Kentucky, can’t talk about the topic right now. He’s too busy caring for people who he says don’t take care of themselves.

“I just had to go take care of man that left our hospital this morning and now has gone and got drunk and will suck up more health care dollars,” Spady wrote in a hurried e-mail late on a recent weeknight.

That same day, he cared for a 358-pound man with diabetes who didn’t take his medication for two days and then stayed up all night playing poker, plus five different people who overdosed on prescription drugs.

“It just makes me very upset when I have to pay more and more taxes to support government health care programs and have to work longer and longer hours to help a lot of people that just don’t seem to care,” he wrote.

It’s not that Spady lacks compassion. He’s been on medical missions to Mexico and Haiti and has donated thousands of hours of free care in the Appalachian community where he’s worked for nearly a quarter century.

Video: Health care fight scaring seniors?
But Spady is part of a growing chorus of medical professionals, researchers and ordinary citizens who contend that the touchy topic of individual responsibility has been all but ignored in the debate about how to reform the nation’s health care system — and how to pay for it.

"Seldom does anyone suggest how — or if — the individual's role should be reformed," argued Lisa Herrington, 46, a former health industry administrator who launched a discussion of the topic in May on the blog "Thoughts that Make You Think."

"Having health insurance coverage doesn't make a person healthy. It's what you do with that coverage and your personal choices that make the difference," she added.

Critics say members of Congress who've headed home for summer recess leaving no fewer than five Democratic health reform plans up in the air should be as concerned about encouraging individual accountability as they are with extending insurance coverage to 46 million Americans.

‘It's simple fairness’
“If you talk about costs, there’s something here and now that you can do,” said John F. Banzhaf, director of the anti-smoking agency Action on Smoking and Health, which has pressured members of Congress to enact a $60 a month user fee to make smokers pay part of the health insurance costs of their habit.

“If you don’t have a user fee on smokers, that forces everyone else to pay those health care costs,” said Banzahf, who is also a professor of public interest law at George Washington University Law School. “One argument is that it’s simple fairness.”

But other experts caution that the conversation about personal responsibility is not so simple. For one thing, many Americans don’t agree that smokers, the obese or others should pay higher costs for health care based on their unhealthy habits.

Only 37 percent of U.S. adults thought it was fair to charge people with unhealthy lifestyles more for their care in 2007, down from 53 percent just a year earlier, according to Wall Street Journal Online/Harris Interactive Healthcare polls.

Asked specifically about smoking versus obesity, they came down harder on the puffers, with 57 percent favoring higher insurance rates for smokers, but only 36 percent saying the same for those who are overweight. Humphrey Taylor, chairman of the Harris Poll, said that's not surprising in a country where two-thirds of adults are overweight and 20 percent still smoke.

In some ways, those with insurance are already helping to cover those without. Insured patients pay higher costs on hospital fees, for example, to help balance out the bills of those who don't have coverage.

Growing outrage over high health care costs racked up by others' excess isn't hard to find. Message boards on msnbc.com stories related to health and health reform are filled with frustrated posters.

"People need to get their lives together. If you can get down to a healthy weight, I suggest you do so," one commenter noted. "You will save yourself, and everybody else, a lot of stress and money."

"Make fat people pay more for health care, tax them where you can, just like smokers pay more for everything," wrote another. "Ride a motorcycle and pay more and so on. Tired of paying for everyone else's stupidity."

The catch is, not everyone can agree which health problems are the responsibility of the individual, and which are wider social concerns. Rob Gould, president of the Partnership for Prevention, a Washington, D.C., nonprofit agency aimed at decreasing disease, said he’s all for individuals becoming invested in their own good health, but notes that the community must make it easier.

“We can’t allow ‘personal responsibility,’ in quotes, to become a polite way of saying, ‘You’re on your own, Mac,’” Gould said. “When kids don’t have a way to safely bike or walk to school because there are no sidewalks, that’s not personal responsibility.”

There's also the question of where to draw the line on personal responsibility. If smoking and obesity can be fined, and motorcycle riders need to pay higher insurance rates, it opens the door to penalizing other preventable risks. Could the same logic be applied to people who have unprotected sex and turn up with a disease? Those who eat their beef on the rare side despite warnings about E. coli contamination?

Obesity health costs: $147 billion a year
There’s no doubt that the bulk of the nation’s health care costs are self-inflicted. Smoking, high blood pressure and being overweight are the top risks for early death, accounting for more than 1 million premature deaths each year, with physical inactivity, high blood sugar and alcohol use not far behind, according to an April study by the Harvard School of Public Health.

The price tag for obesity has soared to $147 billion a year, new government studies show, and smoking costs about $193 billion in medical expenses and lost productivity.

“To have hundreds of thousands of premature deaths caused by these modifiable risk factors is shocking," noted Goodarz Danaei, a co-author of the Harvard risk study.

Forcing the issues?
Such results, Danaei said, should force public health officials to consider whether they're looking at the right ways to influence better behavior.

To date, the answer appears to be no, said Joan Alker, co-executive director Georgetown University Health Policy Institute Center for Children and Families. One glaring failure is a 2006 West Virginia Medicaid experiment that aimed to increase personal responsibility by requiring patients to sign agreements promising to be healthy.

Under the plan, patients agreed to follow their doctors' advice and to generally aim to improve their health.

Those who signed up got enhanced health care including nutrition education and free stop-smoking and chemical dependency programs. Those who didn’t sign up got limited basic services.

Even so more than 90 percent of the participants failed even to sign the health agreement, let alone follow the advice. The bottom line was that children, who made up 85 percent of those enrolled, were penalized because of the actions of their parents.

“I don’t think it’s good to impose a stick approach, particularly on children,” said Alker, who analyzed the program two years later.

But some so-called “carrot” approaches, programs that offer incentives for healthful behaviors, don’t seem to work any better. A Florida Medicaid program that offers drug store points that patients can accumulate for keeping doctor's appointments or getting their kids immunized has failed to motivate meaningful change, Alker said.How does your state rank?

Part of the problem is that many people may not be in a position to make healthful choices, Alker said. It can be cheaper to feed a family fast food than fresh vegetables, especially in areas where there are no supermarkets, for instance. A mother might miss a doctor’s appointment if she’s having transportation trouble. And everyone is subject to the pressures of a culture in which bad health behaviors are routinely glorified by advertisers.

“We just have to remind ourselves that individual choice is taking place in a social context,” she added.

Obese people, in particular, struggle with that context, said James Zervios, a spokesman for the Obesity Action Coalition in Tampa, Fla. At the same time they're surrounded by lavish depictions of fattening food, overweight people are blamed for skyrocketing health care costs.

"As much as society and the media likes to say, 'Back away from the table, don't eat the doughnut,' it's a lot harder than that," said Zervios.

Any health care overhaul plan needs to provide not only education about prevention, but ample treatment options for people who are already overweight, he said.

Is personal responsibility simply inconvenient?
That may be true, but there’s also something to be said for simply stepping up when it comes to one’s own health, noted Lisa Herrington, the woman who raised the issue on the public blog.

During last year's campaign, President Barack Obama said the success of health reform hinged on individual actions. "Preventative care works only if Americans take responsibility for their health and make the right decisions for their own lives — if they eat the right foods, stay active and stop smoking," Obama said in a statement.

But Herrington said she hasn't heard such comments since. “Is personal responsibility an inconvenient topic in the health care reform debate?” she asked.

“I find that people don’t think about the choices they’re making and how they impact the costs of health care down the road,” Herrington said. “Health care is never going to cost less until we control this other piece, until we get a hold on this personal responsibility piece.”

That’s a thought echoed by Steve Spady as he headed back into the emergency room where he sees 25 to 30 patients in a 12-hour shift.

“We should have compassion, and do have it, for the situation that many patients are in. The problem is what program is best to help them help themselves.”